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Translating Developmental Science into Healthy Lives PowerPoint Presentation

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Description : This presentation tries to provide a generalist’s overview of advances in developmental science, present ecobiodevelopmental framework and discuss ways early childhood professionals (ECPs) might collaborate to translate science into healthier lives.

Tags : early childhood professionals, ECPs, Pediatric, pediatrician, children, children hospitals

Published on : Jul 04, 2020 | Views : 1251 | Downloads : 0

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Slide 1-

Translating Developmental Science into Healthy Lives: Andrew Garner, M.D., Ph.D., F.A.A.P. University Hospitals Medical Practices, and Associate Clinical Professor of Pediatrics, Case Western Reserve School of Medicine, and Center for Child Health and Policy, Rainbow Babies and Children’s Hospital Realizing the Potential
Slide 2-

My 3 Objectives For Today Provide a generalist’s overview of advances in developmental science Present an organizing, integrated, ecobiodevelopmental framework Discuss ways early childhood professionals (ECPs) might collaborate to translate science into healthier lives
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Critical Concept #1 Childhood Adversity has Lifelong Consequences. Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later.
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Prevalence of Adverse Childhood Experiences (ACE) Girls Boys Total (n=9,367) (n=7,970) (17,337) Abuse – Emotional 13.1% 7.6% 10.6% Household Dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness 13.7% 29.5% 23.3% – Parental Separation or Divorce 24.5% – Incarcerated Household Member 5.2% 11.5% 23.8% 14.8% 21.8% 4.1% 12.7% 26.9% 19.4% 23.3% 4.7% Neglect * *Wave 2 data only (n=8,667) Source: Kaiser ACE Study, 1 995-1997. Data from : www.cdc.gov/nccdphp/ace/demographics
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ACEs Skeletal Fractures General Health and Social Functioning Risk Factors for Common Diseases Hallucinations ACEs Impact Multiple Outcomes Married to an Alcoholic Difficulty in job performance Relationship Problems High perceived stress Smoking Alcoholism Promiscuity Obesity Multiple Somatic Symptoms IV Drugs High Perceived Risk of HIV Poor Perceived Illicit Drugs Health Ischemic Heart Disease Sexually Transmitted Diseases Cancer Prevalent Diseases Liver Disease Chronic Lung Disease Early Age of First Intercourse Sexual Dissatisfaction Sexual Health Teen Paternity Teen Pregnancy Depression Mental Health Anxiety Sleep Disturbances Memory Disturbances Panic Reactions Poor Anger Control Fetal Death Unintended Pregnancy Poor Self- Rated Health
Slide 6-

Adverse Childhood Experiences Adoption of Health-Risk Behaviors Social, Emotional, and Cognitive Impairment Disease & Disability Early Death Death The True Nature of Preventive Medicine Birth Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status Slide modified from V. J. Felitti ??
Slide 7-

Developing a Model of Human Health and Disease Life Course Science Early childhood ecology strongly associates with lifelong developmental outcomes What are the mechanisms underlying these well-established associations? How do you begin to define or measure the ecology?
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Defining Adversity or Stress How do you define/measure adversity? Huge individual variability Perception of adversity or stress (subjective) Reaction to adversity or stress (objective) National Scientific Council on the Developing Child (Dr. Jack Shonkoff and colleagues) Positive Stress To lerable Stress Based on the REACTION (objective physiologic responses) Toxic Stress
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Defining Adversity or Stress Positive Stress Brief, infrequent, mild to moderate intensity Most normative childhood stress Inability of the 15 month old to express their desires The 2 year old who stumbles while running Beginning school or daycare The big project in middle school Social-emotional buffers allow a return to baseline (responding to non-verbal clues, consolation, reassurance, assistance in planning) Builds motivation and resiliency Positive Stress is NOT the ABSENCE of stress
Slide 10-

Defining Adversity or Stress Toxic Stress Long lasting, frequent, or strong intensity More extreme precipitants of childhood stress (ACEs) Physical, sexual, emotional abuse Physical, emotional neglect Household dysfunction Insufficient social-emotional buffering (Deficient levels of emotion coaching, re-processing, reassurance and support) Potentially permanent changes and long-term effects Epigenetics (there are life long / intergenerational changes in how the genetic program is turned ON or OFF) Brain architecture (the mediators of stress impact upon the mechanisms of brain development / connectivity)
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Critical Concept #2 Epigenetics: Which genes are turned on/off, when, and where Ecology (environment/experience) influences how the genetic blueprint is read and utilized Ecological effects at the molecular level Stress-induced changes in epigenetic switches (and gene expression) “Genes may load the gun, but the environment pulls the trigger”
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Biology Physiologic Adaptations and Disruptions Life Course Science Through epigenetic mechanisms, the early childhood ecology becomes biologically embedded, influencing how the genome is utilized Developing a Model of Human Health and Disease
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Critical Concept #3 Developmental Neuroscience: Brain Architecture is experience dependent (both individual connections or “synapses” and complex circuits of connections are dependent upon activity) Ecology (environment/experience) influences how brain architecture is formed and remodeled (plasticity) Diminishing cellular plasticity limits remediation Early childhood adversity -> vicious cycle of stress Potentially permanent alterations in brain architecture and functioning
Slide 14-

Two Types of Plasticity Synaptic Plasticity – Variation in the STRENGTH of individual connections “from a whisper to a shout” Lifelong (how old dogs learn new tricks) Cellular Plasticity – Variations in the NUMBER (or COUNT) of connections “ from one person shouting to a stadium shouting” Declines dramatically with age (waning by age 5)
Slide 15-

Brain Stem & Cranial Nerves: Vital functions Swallowing Cerebellum: Smooth movements Coordination Occipital Lobe: Visual processing Parietal Lobe: Integration of sensory data and movement Temporal lobe (outside): Processing sound and language Frontal lobes: Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences Differential Brain Maturation Limbic System (inside): Emotions and impulsivity + The Gas Pedal + Amygdala - The Brake – PFC (with some hippocampal help)
Slide 16-

Out of Balance? Prefrontal Cortex Cold Cognition Judgmental Reflective Calculating Think about it Biological maturity by 24 Amygdala Hot Cognition Emotional Reactive Impulsive Just do it Biological maturity by 18 Adapted from Ken Winters, Ph.D.
Slide 17-

Impact of Early Stress Chronic “fight or flight;” cortisol / norepinephrine Changes in Brain Architecture Hyper-responsive stress response; calm/coping CHITLODXHIOCOSDTRSETSRSESS
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Biology Physiologic Adaptations and Disruptions Life Course Science Declining plasticity in the developing brain results in potentially permanent alterations in brain functioning and development Developing a Model of Human Health and Disease
Slide 19-

Eco-Bio-Developmental Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions The Basic Science of Pediatrics Life Course Science Ecology Becomes biology, And together they drive development across the lifespan
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Critical Concept #4 The Science of Early Brain and Child Development Epigenetics Physiology of Stress Neuroscience Education Health Economics One Science – Many Implications The critical challenge now is to translate game-changing advances in developmental science into effective policies and practices for families w/ children to improve education, health and lifelong productivity
Slide 21-

Though grounded in developmental science, the simplicity of the EBD framework may promote understanding as well as support for translation Psychosocial stressors and other salient features of the ecology are every bit as biological as nutrition or lead (no distinction between mental and physical health, just healthy vs. unhealthy development) Emphasizes the dimension of time – to reflect the on-going, cumulative nature of benefits and threats to health and wellness Advantages of an EBD Framework
Slide 22-

Development results from an on-going, re- iterative, and cumulative dance between nurture and nature Brain Development Alterations in Brain Structure and Function Experience Protective and Personal (versus Insecure and Impersonal) Epigenetic Changes Alterations in the Way the Genetic Program is Read Behavior Adaptive or Healthy Coping Skills (vs. Maladaptive or Unhealthy Coping Skills)
Slide 23-

Underscores the need to improve the early childhood ecology in order to: Mitigate the biological underpinnings for educational, health and economic disparities Improve developmental/life-course trajectories HOW to change the early childhood ecology? Highlights the pivotal role of toxic stress Not just “step on the gas” or enrichment But “take off the brake” by treating, mitigating or immunizing against toxic stress Advantages of an EBD Framework
Slide 24-

Models Maslow’s Hierarchy of Needs (Theoretical - 1943) ASCD’s Whole Child Education (Implementation) America’s Promise Alliance (Evidence-based) Needs Self-Actualization An effective education Need to know, explore and understand Each student is actively engaged in learning Esteem Need to achieve and Each student has numerous Opportunities to contribute opportunities Reinventing the Wheel -All over again? Unmet needs are potential sources of STRESS !!
Slide 25-

Childhood Adversity Poor Adult Outcomes Toxic Stress Epigenetic Modifications Disruptions in Brain Architecture Behavioral Allostasis Linking Childhood Experiences and Adult Outcomes
Slide 26-

The BIG Questions are… If TOXIC STRESS is the missing link between ACE exposure and poor adult outcomes, it raises the following BIG questions: Are there ways to: treat, mitigate, and/or immunize against the effects of toxic stress? If so, is there a mismatch between: what we KNOW … and … what we actually DO? (may not have time!)
Slide 27-

Addressing Toxic Stress Treatment of the consequences TF-CBT and PCIT are evidence-based Reactive – some “damage” already done! Very COSTLY Efficacy linked to age and chronicity Declining brain plasticity? Insufficient number of / access to providers Limited reimbursements; carve-outs Mental Health Parity? Persistent STIGMA “Character Flaws” vs “Biological Mal-adaptations”
Slide 28-

Secondary / Targeted Preventions Focused, targeted interventions for those deemed to be “at high risk” Visiting Nurse Programs (Nurse Family Partner.) Parenting Programs (Triple-P, Nurturing Parent.) More likely to be effective; minimize “damage” Requires screening (no screen is perfect) Still issues with stigma, numbers of/access to providers Addressing Toxic Stress
Slide 29-

Primary / Universal Prevention Proactive, universal interventions to make stress positive, instead of tolerable or toxic Acknowledges that preventing all childhood adversity is impossible and even undesirable Actively building resiliency (“immunizing” through positive parenting, 7C’s, promoting optimism, formalized social- emotional learning) SE Buffers allow the physiologic stress response to return to baseline Parenting/Caregiver skills for younger children SEL skills for older children (www.casel.org) Addressing Toxic Stress
Slide 30-

Social-Emotional Skills Can Be Taught / Learned
Slide 31-

Critical Concept #5 SOCIAL-EMOTIONAL SKILLS… (a.k.a – Affect Regulation, Non-Cognitive Skills, Mindfulness) …Are learned (they can be modeled, nurtured, taught, practiced, and reinforced) …Effectively buffer against toxic stress (by helping to turn off the physiologic stress response) …Increase test scores (an average of 11 points by meta-analysis!)
Slide 32-

Promoting Parenting Skills in the first 1000 days Parenting is personal – makes pediatricians NERVOUS! “Positive/Nurturing/Supportive” Parenting A Poor investment? Are parenting skills “teachable?” Is there a “ceiling effect” on returns? Or the “Gold Standard?” Shouldn’t this be THE reference point (NOT routine, general, or control populations) Recent article from Luby et al., PNAS Maternal support and Depression severity at ages 3-5 “Waiting Test” assessed the dyad (Bright Gift + Parental Surveys) Hippocampal volumes at school age (7-13) Parenting as Primary Prevention What is “OK?” YES!!
Slide 33-

Luby et al., 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1118003109 Early maternal support exerts a positive influence on hippocampal development The positive effect of maternal support on hippocampal volumes was greater in nondepressed children
Slide 34-

Critical Concept #6 For young children, parent/caregiver support is critical: Turns off physiologic stress response by addressing physiologic and safety needs (PROTECT = Maslow levels 1+2) Turns off the physiologic stress response by promoting healthy relationships and attachment (RELATE = Maslow level 3) Notes and encourages foundational coping skills as they emerge (NURTURE = Maslow levels 4+5) Early Childhood Professionals are ideally placed to: Promote this sort of “Purposeful” Parenting Advocate for a public health approach to address toxic stress
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Universal Primary Preventions Anticipatory guidance Consistent messaging (CTC) No identification No stigma Ceiling effects = Limited evidence base Targeted Interventions (for those “at risk”) Nursing home visits (NFP) Parenting programs (PPP) Early Intervention Less ceiling=More evidence Requires screening Issues with stigma Evidence-Based Treatments (for the symptomatic) PCIT; TB-CBT; Pharmacotx Treatment works! Screening / stigma / access Social-Emotional Safety Nets A Public Health Approach to “Toxic Stress”
Slide 36-

Universal Primary Preventions Bright Futures Connected Kids / NCH Circle of Security / ZTT Relationships as a “vital” sign Decrease Stress/Build Skills Targeted Interventions Screening for risks (assess the ecology) Refer to/advocate for EBI Collaborating/Developing EBI ID Risks/Provide EBI Evidence-Based Treatments Screening for diagnoses Common factors approach Refer for/advocate for EBT Collaborating/Developing EBT ID Symptoms/Provide EBT WHAT are we DOING?!
Slide 37-

Public Health Implications ACE data provide a working model for understanding and addressing the childhood antecedents of adult disease. Is there a gap between what we do and what we know? What we DO: 95% of the trillions of dollars that we spend on health is on treatment and NOT prevention
Slide 38-

What we KNOW: That 70% of early deaths are preventable, with… The majority (40% overall) due to behavioral patterns that lead to chronic disease. Behavioral Allostasis due to toxic stress? Public Health Implications McGinnis, Williams-Russo and Knickman, 2002
Slide 39-

Proximal Causes of Death: Chronic Disease Acute causes of death are the exception, not the rule
Slide 40-

Distal Causes of Death: Unhealthy Lifestyles If these unhealthy lifestyles are manifestations of behavioral allostasis, a FUNDAMENTAL cause of death is TOXIC STRESS!
Slide 41-

By 2030, 90% of the morbidity in high income countries will be due to Non-Communicable Diseases Most NCDs are do to unhealthy behaviors (overeating, smoking, alcohol, promiscuity, and illicit drugs)
Slide 42-

How do those automatic processes form in the first place!?
Slide 43-

A Public Health Dilemma: Do we continue to treat disease, the unhealthy lifestyles that lead to disease, or the TOXIC STRESS that leads to the adoption of unhealthy lifestyles??
Slide 44-

A Public Health Parable: Man by the river hears someone drowning Being a good swimmer, he rescues the person Before catching his breath, he hears another in need, and another and another… The man, exhausted, begins to walk away Asked where he’s going, he responds…
Slide 45-

“I’m going upstream to prevent others from falling in!!” A Public Health Parable:
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SUMMARY What is Toxic Stress? A physiologic stress response that is excessive or prolonged (reflects an inability to “turn it off”) Results in potentially permanent changes in: Gene expression (epigenetics) Brain development (neuroscience) Behavior (allostasis)
Slide 47-

SUMMARY Why should I care? Toxic stress is a MEDIATOR between early childhood adversity and less than optimal outcomes in learning, behavior and health Understanding the BIOLOGY underlying these well established associations opens up new opportunities for primary prevention and early intervention
Slide 48-

Childhood Adversity Poor Adult Outcomes Linking Childhood Experiences and Adult Outcomes
Slide 49-

Childhood Adversity Poor Adult Outcomes Linking Childhood Experiences and Adult Outcomes Toxic Stress Epigenetic Modifications Disruptions in Brain Architecture Improve caregiver/community capacity to prevent or minimize toxic stress (e.g. – efforts to promote the safe, stable and nurturing relationships that turn off the physiologic stress response) Behavioral Allostasis Maladaptive behaviors Non-communicable Diseases Improve caregiver/community capacity to promote healthy, adaptive coping skills (e.g. - efforts to encourage rudimentary but foundational SE, language, and cognitive skills)
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SUMMARY What can I do? Understand the ecobiodevelopmental framework (advocate for a collaborative, public health approach to address toxic stress) Help children figure out how to turn off their stress response (parent/child skills) Intervene early for those children who appear unable to turn off their stress response (secondary and tertiary prevention)
Slide 51-

It is easier to build strong children than to repair broken men. CONCLUSION: Frederick Douglass

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MarieAltmann

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